Circulating neprilysin hypothesis: A new opportunity for sacubitril/valsartan in patients with heart failure and preserved ejection fraction?

Josep Lupón; Evelyn Santiago-Vacas; Germán Cediel; Pau Codina; Mar Domingo; Elena Revuelta-López; Elisabet Zamora; Giosafat Spitaleri; Javier Santesmases; Julio Núñez; Antoni Bayes-Genis

doi:10.1371/journal.pone.0249674

Peer Review History

Original SubmissionJanuary 4, 2021
24 Feb 2021 Decision Letter - Yoshiaki Taniyama, Editor PONE-D-21-00228 Circulating neprilysin hypothesis: a new opportunity for Sacubitril/Valsartan in patients with heart failure and preserved ejection fraction? PLOS ONE Dear Dr. Lupón, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Both of the reviewers regard this paper important, but the author had better to show how many patients screened to get to their numbers, and if serum was collected and stored, when was it analyzed? Please submit your revised manuscript by Apr 10 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. 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Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: 1- Hypothesis properly outlined in the Introduction 2- Methods: Were samples collected on patients, stored and then all analyzed with the same assay at once or analyzed over a 10-year period? sNEP is not an assay normally processed in regular hospital laboratories. This needs to be clarified before accepting for publication 3- CV death: defined by the authors. Appropriate follow up and tracking of events/outcomes. 4- Results: Can the authors provide the number of patients screened for this study? Unclear how many patients screened – must be clarified prior to publication 5- Table 1: demographics are consistent with previous studies (HFPEF vs. HFREF) 6- Hidralazine (Table 1) should be spelled hydralazine 7- Table 2: Data similar to other studies i.e. worse outcomes in patients with HFREF vs. HFPEF 8- Discussion: appropriate comments made on results. Discussion of limitations of testing Reviewer #2: Lupon et. al. present results from a large cohort of patients with HF hospitalized over a 10-year period. sNEP is measured and associations are examined among those with and without preserved EF (>=57%) and above and below median of sNEP. The association between sNEP and outcomes in HFpEF patients warrants further external validation. Further, whether only those who have elevated sNEP will benefit from ARNI will require further studies. These limitations are nicely outlined. Additional investigations could consider: -AUC for sNEP in patients with and without pEF -Remove either the event-free survival or cumulative incidence as this information is redundant in the figure -Add discussion about whether sNEP could be used before HFpEF develops to predict risk for HF ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0249674.r001
Revision 1
2 Mar 2021 Author Response Reviewer #1: 1- Hypothesis properly outlined in the Introduction. Thank you. 2- Methods: Were samples collected on patients, stored and then all analyzed with the same assay at once or analyzed over a 10-year period? sNEP is not an assay normally processed in regular hospital laboratories. This needs to be clarified before accepting for publication. We appreciate your comment and apologize for the generated doubts. Blood samples were collected and stored at -80°. Afterwards they were processed in two time-periods: 1069 patients in June-July 2014 and the rest in November 2018. We clarify this aspect in the methods section: “…Blood samples were obtained between 09:00 am and 12:00 pm and stored at at -80º and analyzed without previous freeze-thaw cycles. Analyses were performed in two time periods: June-July 2014 in the first 1069 patients and November 2018 in the rest”. 3.-CV death: defined by the authors. Appropriate follow up and tracking of events/outcomes. Thank you. 4- Results: Can the authors provide the number of patients screened for this study? Unclear how many patients screened – must be clarified prior to publication. Thank you for the comment. We clarify this question in the revised version of the manuscript: “Circulating sNEP was measured in 1,428 patients with HF who were consecutively enrolled in the study from May 2006 to February 2016, out of the 1,765 patients who were attended during this period time. No clinical criteria for exclusion were established and only consent and availability of blood sample determined the included patients”. 5- Table 1: demographics are consistent with previous studies (HFPEF vs. HFREF). We agree with the comment. 6- Hidralazine (Table 1) should be spelled hydralazine Done. 7- Table 2: Data similar to other studies i.e. worse outcomes in patients with HFREF vs. HFPEF. In the revised version of the manuscript we added the following sentence in the limitations section: “…Due to the worse prognosis observed, we cannot discard a selection bias in our patients with LVEF >57%”. 8- Discussion: appropriate comments made on results. Discussion of limitations of testing. We appreciate your comment. In the revised version of the manuscript we added the following limitation: “…Technical limitations of the assay should be acknowledged. Only circulating soluble NEP was assessed, but in humans NEP is widely expressed in several organs, and thus the results reported here might underrepresent overall NEP expression and activity. Furthermore, the experimental assay we used for sNEP determination has long incubation times and it is not ready for clinical use. Up to our knowledge there are no marketed immunoassays approved in clinical practice. Due to the worse prognosis observed, we cannot discard a selection bias in our patients with LVEF >57%..” Reviewer #2: Lupon et. al. present results from a large cohort of patients with HF hospitalized over a 10-year period. sNEP is measured and associations are examined among those with and without preserved EF (>=57%) and above and below median of sNEP. The association between sNEP and outcomes in HFpEF patients warrants further external validation. Further, whether only those who have elevated sNEP will benefit from ARNI will require further studies. These limitations are nicely outlined. Additional investigations could consider: -AUC for sNEP in patients with and without pEF. Thank you for suggestion. We choose Harrell’s C-statistic because it takes into account time-to-event, although it always gives lower numbers that AUC by logistic regression. In the revised version of the manuscript we added: “Harrell’s C-statistic for sNEP above/below the median, taking also in consideration age and sex, was 0.730 (0.682-0.779) in patients with LVEF >57% and 0.677 (0.664-0.776) in patients with LVEF ≤57% for the primary composite end-point, and 0.704 (0.643-0.765) and 0.629 (0.603-0.655), respectively, for the secondary composite end-point of cardiovascular death or HF hospitalization)”. -Remove either the event-free survival or cumulative incidence as this information is redundant in the figure. We apologize for the lack of clarity. As mentioned in the figure legend, left panel (A) represents event-free survival for the composite end-point of all-cause death or HF hospitalization, while right panel (B) represents cumulative incidence of the composite end-point of cardiovascular death or HF hospitalization (with competing risk taken into account in the analysis). We clarify this in the reviewed figure. -Add discussion about whether sNEP could be used before HFpEF develops to predict risk for HF Thank you for your recommendation. In the revised version of the manuscript we added the following paragraph in the Discussion section: “Up to or knowledge sNEP levels have not been evaluated for diagnostic purposes in HF. With the hypothesis that higher sNEP levels would correlate with lower natriuretic peptide levels, worse diastolic function, and subsequent clinical incident HFpEF, Reddy et al. [20] performed a population study with 1,536 participants from Olmsted County, Minnesota. The authors found that low sNEP was paradoxically associated with worse diastolic dysfunction and hypertension but not with outcomes, including incident HF over a median of 10.7 years of follow-up.” [20] Reddy YNV, Iyer SR, Scott CG, Rodeheffer RJ, Bailey K, Jenkins G, et al. Soluble Neprilysin in the General Population: Clinical Determinants and Its Relationship to Cardiovascular Disease. J Am Heart Assoc. 2019; 8: e012943. doi: 10.1161/JAHA.119.012943. Attachments Attachment Submitted filename: Response to reviewers-Plos One.docx https://doi.org/10.1371/journal.pone.0249674.r002
23 Mar 2021 Decision Letter - Yoshiaki Taniyama, Editor Circulating neprilysin hypothesis: a new opportunity for Sacubitril/Valsartan in patients with heart failure and preserved ejection fraction? PONE-D-21-00228R1 Dear Dr. Lupón, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Yoshiaki Taniyama, MD, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): The author responded the problems. Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: previous concerns are addressed. Acceptable for publication. Concerns regarding the description of the study population was addressed in the revised manuscript ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No https://doi.org/10.1371/journal.pone.0249674.r003
Formally Accepted
1 Apr 2021 Acceptance Letter - Yoshiaki Taniyama, Editor PONE-D-21-00228R1 Circulating neprilysin hypothesis: a new opportunity for Sacubitril/Valsartan in patients with heart failure and preserved ejection fraction? Dear Dr. Lupón: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Yoshiaki Taniyama Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0249674.r004

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